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Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children: A Wake-Up Call for the Pediatric Critical Care Community*

Kudchadkar, Sapna R. MD1,2; Yaster, Myron MD1,2; Punjabi, Naresh M. MD, PhD3,4

doi: 10.1097/CCM.0000000000000326
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Objectives: To examine pediatric intensivist sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children.

Design: An international, online survey of questions regarding sedative and analgesic medication choices and availability, sedation protocols, sleep optimization, and delirium recognition and treatment.

Setting: Member societies of the World Federation of Pediatric Intensive and Critical Care Societies were asked to send the survey to their mailing lists; responses were collected from July 2012 to January 2013.

Subjects: Pediatric critical care providers.

Interventions: Survey.

Measurements and Main Results: The survey was completed by 341 respondents, the majority of whom were from North America (70%). Twenty-seven percent of respondents reported having written sedation protocols. Most respondents worked in PICUs with sedation scoring systems (70%), although only 42% of those with access to scoring systems reported routine daily use for goal-directed sedation management. The State Behavioral Scale was the most commonly used scoring system in North America (22%), with the COMFORT score more prevalent in all other countries (39%). The most commonly used sedation regimen for intubated children was a combination of opioid and benzodiazepine (72%). Most intensivists chose fentanyl as their first-line opioid (66%) and midazolam as their first-line benzodiazepine (86%) and prefer to administer these medications as continuous infusions. Propofol and dexmedetomidine were the most commonly restricted medications in PICUs internationally. Use of earplugs, eye masks, noise reduction, and lighting optimization for sleep promotion was uncommon. Delirium screening was not practiced in 71% of respondent’s PICUs, and only 2% reported routine screening at least twice a day.

Conclusions: The results highlight the heterogeneity in sedation practices among intensivists who care for critically ill children as well as a paucity of sleep promotion and delirium screening in PICUs worldwide.

Supplemental Digital Content is available in the text.

1Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, MD.

2Department of Pediatrics, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, MD.

3Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

4Department of Epidemiology, Johns Hopkins University School of Medicine, Baltimore, MD.

* See also p. 1724.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Kudchadkar was supported by the Johns Hopkins CTSA Award Number 5KL2RR025006 from the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH). Dr. Kudchadkar is employed by Johns Hopkins University School of Medicine. Dr. Kudchadkar and her institution received grant support from the Johns Hopkins Institutional KL2 (CTSA) grant. Dr. Yaster consulted for Endo Pharma, Purdue Pharma, and PRA; is employed by JHU; provided expert testimony (legal reviews); and received grant support from the NIH and Smiths Medical. Dr. Punjabi received support for article research from the NIH (HL075078). His institution received grant support from Resmed and Respironics.

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© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins